Brugada phenocopy: new terminology and proposed classification

Do breast implants not cause an increased rate of abnormal electrocardiograms (ECG)?

BACKGROUND

Breast implants interfere may interfere with surface ECG recording. The goal of this study was to evaluate if the presence of breast implants can lead to abnormal electrocardiogram (ECG) using a large database in adults.

METHODS

Using ICD 10 codes for breast implants and abnormal ECG, we evaluated any association between abnormal ECG coding in adult women with breast implants compared to women without breast implants utilizing the National Inpatient Sample (NIS) database. Using different age cutoffs showed similar results.

RESULTS

A total of 252,200 women in the NIS database had coding for abnormal EKG over age 18. There were no differences in the presence of abnormal EKG in women with or without breast implants (0.28% vs 0.3%, P = 0.64, OR: 1.02, CI: 0.72-1.32, p = 0.89). After multivariate adjustment for age, baseline characteristics, and comorbid conditions, women with or without breast implants had similar rates of abnormal ECG.

CONCLUSION

Using a large database, we could not find any effect of breast implants on ECG recording suggesting that breast implant has no significant interference with ECG.

Brugada phenocopy vs. Brugada syndrome: Delineating the differences for optimal diagnosis and management

Brugada syndrome (BrS) is a genetic disorder known for its characteristic electrocardiogram (ECG) patterns and increased risk of sudden cardiac death. Brugada phenocopy (BrP) presents similar ECG patterns but is distinguished by its reversible nature when the underlying conditions are resolved. This article delineates the intricacies of BrP, emphasizing its etiology, clinical presentation, diagnosis, treatment, and prognosis. The article categorizes BrP based on various underlying causes, including metabolic disturbances, myocardial infarction, and mechanical compression, among others. It also underscores the critical importance of differentiating BrP from BrS to avoid misdiagnosis and inappropriate treatment, such as unnecessary implantation of cardioverter-defibrillators. The reversible aspect of BrP underlines the necessity for an etiology-specific approach to treatment, which not only prevents cardiac death but also highlights the significance of understanding the dynamic nature of ECG patterns. Through an exploration of case studies and current research, this review advocates for increased awareness and further investigation into BrP. It aims to enhance the diagnostic accuracy and management strategies, thereby improving the prognosis for patients presenting with Brugada-like ECG patterns. The review culminates in a call for further research to close existing knowledge gaps and improve patient outcomes.

Severe hypothyroidism as a trigger for Brugada-type ECG abnormalities: a case report and literature review

Brugada syndrome (BrS) is an inherited disorder that can cause ventricular fibrillation and sudden cardiac death in individuals with otherwise structurally normal hearts. Several provoking factors are known to potentially unmask or exacerbate a typical Brugada ECG pattern in predisposed subjects. Hypothyroidism has been suggested as one of these triggers, but the exact mechanisms underlying this relationship remain poorly understood. Moreover, the severity of thyroid dysfunction beyond which a Brugada-type ECG alteration might be triggered is still unclear. We report the case of a 33-year-old male who displayed a Brugada type 1 ECG pattern and was diagnosed with severe hypothyroidism (TSH > 100 mU/L with undetectable levels of fT4 and fT3). Hormonal replacement therapy with levothyroxine was initiated at increasing doses; serial biochemical and ECG controls were performed, initially every 3 weeks up to 15 weeks and afterward every 3 months. The regression of typical Brugada ECG waveforms could be seen at an early stage, when the patient was still taking a low dose of levothyroxine (37.5 µg/day, i.e., one-fourth of his final requirements of 150 µg/day), and laboratory tests still showed a marked alteration of thyroid hormonal parameters. Hypothyroidism may act as a trigger for Brugada-type ECG abnormalities, but a very severe alteration of the hormonal parameters is necessary to prompt these alterations. In our case, the initiation of replacement therapy with levothyroxine rapidly reversed the ECG modifications, even at a low subtherapeutic dose.

Clinical Management of Brugada Syndrome: Commentary From the Experts

Although there is consensus on the management of patients with Brugada Syndrome with high risk for sudden cardiac arrest, asymptomatic or intermediate-risk patients present clinical management challenges. This document explores the management opinions of experts throughout the world for patients with Brugada Syndrome who do not fit guideline recommendations. Four real-world clinical scenarios were presented with commentary from small expert groups for each case. All authors voted on case-specific questions to evaluate the level of consensus among the entire group in nuanced diagnostic and management decisions relevant to each case. Points of agreement, points of controversy, and gaps in knowledge are highlighted.

Brugada phenocopy associated with multiple psychotic drugs

Brugada phenocopy (BrP) is a clinical condition characterized by transient ECG changes of Brugada syndrome (BrS), which can be due to various clinical conditions. We describe a case report of BrP due to psychotic drugs.

Induction of Brugada electrocardiogram pattern with aluminum phosphide poisoning: a case report

Introduction and importance

Aluminum phosphide (ALP) is a commonly used suicidal agent in an agrarian country like Nepal. The unmasking of the Brugada pattern in the electrocardiogram (ECG) associated with ALP poisoning is a rare phenomenon, and studies pertaining to it are scarce in the medical literature.

Case presentation

An 18-year-old female presented to the emergency department with multiple episodes of vomiting, headache, blurring of vision, and abdominal pain after 4 h of consumption of ALP with suicidal intent. A 12-lead ECG revealed a coved ST-segment elevation and T-wave inversion in leads V1-V3 with right bundle branch block suggestive of a type 1 Brugada pattern. Her past medical and family history was not significant. The patient made an uneventful recovery with the required supportive treatments.

Clinical discussion

Cardiac arrhythmias are the major cause of death in ALP poisoning. Unmasking of the Brugada ECG pattern is a rare but potentially fatal complication implicated in various pharmacological toxicities, including tricyclic antidepressants, cocaine, procainamide, disopyramide, flecainide, and rarely with ALP.

Conclusions

ALP poisoning can unmask the Brugada ECG pattern, which can lead to ventricular fibrillation and/or sudden cardiac death.

Brugada phenocopy with altered ST-segment elevation in pericardial diffuse large B-cell lymphoma and effusive-constrictive pericarditis: a case report

Background

Cardiac lymphoma is a rare disease. Effusive-constrictive pericarditis can be a characteristic of pericardial involvement in patients with this disease. Conversely, a phenotype with electrocardiogram changes similar to those of Brugada syndrome is called Brugada phenocopy, and these changes improve after treatment.

Case summary

A 71-year-old man was transported to our hospital with chest pain, hypotension, and ST-segment elevation in V1 and V2 leads during maintenance dialysis for renal failure. After arrival at the hospital, his ST-segment elevation disappeared, and emergency coronary angiography scan revealed no significant coronary artery stenoses or obstructions. His computed tomography and echocardiography scans revealed pericardial effusion and an intrapericardial mass. Further, his blood pressure dropped and ST-segment elevation recurred during dialysis after 7 days. Thus, pericardiocentesis was performed, but haemodynamic improvement was insufficient, and right catheterization findings suggested effusive-constrictive pericarditis. Meanwhile, flow cytometry of the pericardial fluid suggested the diagnosis of B-cell lymphoma; however, radical chemoradiotherapy was impossible because of cardiogenic shock. The patient died on Day 17. Further, autopsy revealed diffuse large B-cell lymphoma with pericardial and myocardial infiltration.

Discussion

Cardiac lymphoma is rare but can be associated with effusive-constrictive pericarditis, which may be difficult to manage even with pericardial drainage. In such cases, radical treatment, including chemotherapy, should be promptly considered, if possible. Our patient presented with Brugada-type electrocardiogram but no syncope or family history, suggesting Brugada phenocopy and not true Brugada syndrome due to cardiac lymphoma. Notably, temporary improvement in ST-segment elevation was observed despite the absence of treatment.

Diagnostic and therapeutic dilemmas in a patient with myocarditis, Brugada syndrome and arrhythmic syncope

We present a case of a previously healthy 23-year-old male who presented with chest pain, palpitations and spontaneous type 1 Brugada electrocardiographic (ECG) pattern. Positive family history for sudden cardiac death (SCD) was remarkable. Initially, clinical symptoms in combination with myocardial enzymes elevation, regional myocardial oedema with late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and inflammatory lymphocytoid-cell infiltrates in the endomyocardial biopsy (EMB) suggested the diagnosis of a myocarditis-induced Brugada phenocopy (BrP). Under immunosuppressive therapy with methylprednisolone and azathioprine, a complete remission of both symptoms and biomarkers was accomplished. However, the Brugada pattern did not resolve. The eventually spontaneous Brugada pattern type 1 established the diagnosis of Brugada syndrome (BrS). Due to his previous history of syncope, the patient was offered an ICD that he declined. After his discharge he experienced a new episode of arrhythmic syncope. He was readmitted and received an ICD.

Brugada Phenocopy Induced by Hypovolemic Hyponatremia

Brugada syndrome (BrS) is a hereditary channelopathy caused by an autosomal dominant mutation in the cardiac sodium channel gene SCN5A alpha subunit. In individuals without structural heart disease, the risk of sudden cardiac death (SCD) increases in this channelopathy with ST-segment elevation in V1-3 precordials. Brugada phenocopy (BrP) is a condition in which transient ST-segment elevations are observed, mimicking BrS electrocardiographic changes, which can occur with electrolyte and metabolic disorder scenarios. In this study, we share a case of BrP that occurred due to hypovolemic hyponatremia and recovered spontaneously with the correction of electrolyte disturbance.

Autolytic attempt mimicking Brugada type 1 electrocardiogram pattern due to flecainide toxicity. A case report

Background

Brugada phenocopies are a group of heterogeneous disorders that mimic Brugada syndrome (BrS) electrocardiogram (ECG) changes elicited by reversible clinical conditions. We report a novel case on flecainide toxicity causing an ECG signature of Brugada type 1 pattern in the paediatric age.

Case summary

A 13-year-old Caucasian boy with untreated attention-deficit/hyperactivity disorder referred to the Pediatric Emergency Department (PED) after unknown antiarrhythmic drug overdose. He deliberately ingested 10 tablets from a labelled white box of a 100-mg single dose. The ECG showed a coved-type ST-segment elevation in right precordial leads and prolongation of PR segment with a QTc limit interval. Values of troponins gradually increased and echocardiogram was normal. The altered ECG pattern was explained by the stabilizing membrane effect of flecainide involving the inhibition of rapid Na+ channels. After offending drug removal, regression of ECG changes was observed and no cardiac events were documented during follow-up.

Discussion

Flecainide-induced Brugada type 1 ECG pattern may occur in patients with no evidence of genetic susceptibility receiving a toxic dosage of this drug. With increasing dose, its action on conduction pathways manifests as prolongation of PR interval and QT and QRS complex duration and may cause BrS mimicry. A detailed clinical history considering symptoms and ECG findings may support early-raised suspicion for flecainide ingestion. The therapeutic approach implies primary detoxification, prevention of potential triggers, and management of eventual cardiotoxicity events. Finally, risk stratification for BrS should be always measured according to the clinical scenario and surveillance considered in a timely manner.

Cardiac Arrest Due to Brugada Syndrome Associated With Influenza Infection: A Case Report and Literature Review

A 38-year-old Japanese male with no significant medical history but a family history of sudden cardiac death was referred for cardiac arrest. He had a fever (40°C) one day before his visit. His wife reported that he groaned while unconscious, which prompted a referral to the authors' hospital. He was febrile and experienced ventricular fibrillation in the emergency department. After the resolution of ventricular fibrillation, electrocardiography revealed a right bundle branch block with ST-segment elevation in leads V1-3, consistent with a Brugada electrocardiographic pattern; he also tested positive for influenza A infection. Antiarrhythmic and antipyretic agents were administered, and peramivir was initiated; a fatal arrhythmia did not occur. A cardioverter-defibrillator was implanted, and the patient was discharged without complications. Brugada syndrome is a genetic disease that causes fatal cardiac arrhythmias, with fever recognized to induce the Brugada electrocardiographic pattern. The mechanism of the Brugada-type electrocardiographic pattern, right bundle branch block, and ST-segment elevation in the right precordial leads is considered to be the result of an outward shift of ionic currents during early repolarization, causing a marked abbreviation of the action potential in epicardial cells of the right ventricle. Activation and inactivation kinetics for early sodium currents are faster at higher temperatures. To date, there have only been four published reports describing Brugada-like electrocardiographic changes associated with fever related to influenza infection, and this is the first report of cardiac arrest. Since influenza infection can cause high fever and trigger the fetal arrhythmia of Brugada syndrome, it is important to shorten the duration of the fever. Anti-influenza therapy may be considered in patients who have a history of sudden cardiac arrest in the family, as influenza may influence the development of the Brugada ECG pattern in these individuals. The authors also review the literature on Brugada-like electrocardiographic changes induced by influenza infection. Physicians should be aware that Brugada's electrocardiographic pattern and cardiac arrest can be caused by febrile episodes, including those related to influenza infection.

Not All ST Elevation Is STEMI: Brugada Phenocopy Induced by Hyperkalemia

Brugada syndrome (BrS) is a hereditary channelopathy associated with malignant ventricular arrhythmia and sudden death in individuals with a structurally normal heart. It is characterized by an ST-segment elevation in the precordial leads. Brugada phenocopy (BrP) is a term given to conditions that could result in ST morphologies identical to those found in Brugada syndrome (Brugada pattern electrocardiogram (EKG) changes) without the actual channelopathy responsible for Brugada syndrome. BrP is a rare EKG manifestation of hyperkalemia, commonly seen at high serum levels of potassium, and associated with malignant arrhythmia. Here, we present a case with Brugada pattern EKG changes associated with hyperkalemia and metabolic acidosis, which normalized after correcting the electrolyte abnormalities. In this case, we also wanted to highlight that not all ST-segment elevation is due to myocardial infarction (MI). In young patients with no coronary artery disease (CAD) risk factors, other potential ST elevation causes should be considered.

The r'-Wave Algorithm: A New Diagnostic Tool to Predict the Diagnosis of Brugada Syndrome after a Sodium Channel Blocker Provocation Test

A diagnosis of Brugada syndrome (BrS) is based on the presence of a type 1 electrocardiogram (ECG) pattern, either spontaneously or after a Sodium Channel Blocker Provocation Test (SCBPT). Several ECG criteria have been evaluated as predictors of a positive SCBPT, such as the β-angle, the α-angle, the duration of the base of the triangle at 5 mm from the r'-wave (DBT- 5 mm), the duration of the base of the triangle at the isoelectric line (DBT- iso), and the triangle base/height ratio. The aim of our study was to test all previously proposed ECG criteria in a large cohort study and to evaluate an r'-wave algorithm for predicting a BrS diagnosis after an SCBPT. We enrolled all patients who consecutively underwent SCBPT using flecainide from January 2010 to December 2015 in the test cohort and from January 2016 to December 2021 in the validation cohort. We included the ECG criteria with the best diagnostic accuracy in relation to the test cohort in the development of the r'-wave algorithm (β-angle, α-angle, DBT- 5 mm, and DBT- iso.) Of the total of 395 patients enrolled, 72.4% were male and the average age was 44.7 ± 13.5 years. Following the SCBPTs, 24.1% of patients (n = 95) were positive and 75.9% (n = 300) were negative. ROC analysis of the validation cohort showed that the AUC of the r'-wave algorithm (AUC: 0.92; CI 0.85-0.99) was significantly better than the AUC of the β-angle (AUC: 0.82; 95% CI 0.71-0.92), the α-angle (AUC: 0.77; 95% CI 0.66-0.90), the DBT- 5 mm (AUC: 0.75; 95% CI 0.64-0.87), the DBT- iso (AUC: 0.79; 95% CI 0.67-0.91), and the triangle base/height (AUC: 0.61; 95% CI 0.48-0.75) (p < 0.001), making it the best predictor of a BrS diagnosis after an SCBPT. The r'-wave algorithm with a cut-off value of ≥2 showed a sensitivity of 90% and a specificity of 83%. In our study, the r'-wave algorithm was proved to have the best diagnostic accuracy, compared with single electrocardiographic criteria, in predicting the diagnosis of BrS after provocative testing with flecainide.

Captagon-induced Brugada phenocopy: A report of two cases

Brugada phenocopies (BrP) represent electrocardiogram changes identical to those of true congenital Brugada syndrome but are induced by reversible clinical conditions. Previous cases have been reported in patients following recreational drug use. This report presents two cases of type 1B BrP associated with Fenethylline abuse, a recreational drug known by its trade name, Captagon.

Brugada Phenocopy Caused by Intracranial Hemorrhage

Brugada syndrome (BrS) is a congenital channelopathy associated with an increased risk of malignant ventricular arrhythmias and sudden cardiac death in individuals without any structural cardiopathy. Brugada phenocopies (BrPs) are clinical entities that present electrocardiographic patterns similar to those of BrS that are elicited only under transitory pathophysiological conditions, with normalization of the ECG pattern after the resolution of those conditions. We present a rare case of BrP due to intracranial hemorrhage. We also present and discuss the diagnostic criteria for BrPs and their application to this case.

Brugada Syndrome: From Molecular Mechanisms and Genetics to Risk Stratification

Brugada syndrome (BrS) is a rare hereditary arrhythmia disorder, with a distinctive ECG pattern, correlated with an increased risk of ventricular arrhythmias and sudden cardiac death (SCD) in young adults. BrS is a complex entity in terms of mechanisms, genetics, diagnosis, arrhythmia risk stratification, and management. The main electrophysiological mechanism of BrS requires further research, with prevailing theories centered on aberrant repolarization, depolarization, and current-load match. Computational modelling, pre-clinical, and clinical research show that BrS molecular anomalies result in excitation wavelength (k) modifications, which eventually increase the risk of arrhythmia. Although a mutation in the SCN5A (Sodium Voltage-Gated Channel Alpha Subunit 5) gene was first reported almost two decades ago, BrS is still currently regarded as a Mendelian condition inherited in an autosomal dominant manner with incomplete penetrance, despite the recent developments in the field of genetics and the latest hypothesis of additional inheritance pathways proposing a more complex mode of inheritance. In spite of the extensive use of the next-generation sequencing (NGS) technique with high coverage, genetics remains unexplained in a number of clinically confirmed cases. Except for the SCN5A which encodes the cardiac sodium channel NaV1.5, susceptibility genes remain mostly unidentified. The predominance of cardiac transcription factor loci suggests that transcriptional regulation is essential to the Brugada syndrome's pathogenesis. It appears that BrS is a multifactorial disease, which is influenced by several loci, each of which is affected by the environment. The primary challenge in individuals with a BrS type 1 ECG is to identify those who are at risk for sudden death, researchers propose the use of a multiparametric clinical and instrumental strategy for risk stratification. The aim of this review is to summarize the latest findings addressing the genetic architecture of BrS and to provide novel perspectives into its molecular underpinnings and novel models of risk stratification.

COVID-19 Vaccination-Induced Ventricular Fibrillation in an Afebrile Patient With Brugada Syndrome

A 43-year-old man presented with cardiac arrest 2 days after the second coronavirus disease 2019 (COVID-19) vaccination with an mRNA vaccine. Electrocardiograms showed ventricular fibrillation and type 1 Brugada pattern ST segment elevation. The patient reported having no symptoms, including febrile sensation. There were no known underlying cardiac diseases to explain such electrocardiographic abnormalities. ST segment elevation completely disappeared in two weeks. Although there were no genetic mutations or personal or family history typical of Brugada syndrome, flecainide administration induced type 1 Brugada pattern ST segment elevation. This case suggests that COVID-19 vaccination may induce cardiac ion channel dysfunction and cause life threatening ventricular arrhythmias in specific patients with Brugada syndrome.

Brugada Syndrome Associated with Different Heterozygous SCN5A Variants in Two Unrelated Families

The cardiac sodium channel (Nav1.5) controls cardiac excitability by triggering the action potential of cardiac myocytes and controlling electric impulse transmission. However, it has also been associated with arrhythmogenic cardiomyopathies. Accordingly, genetic variants in SCN5A that result in loss of function of Nav1.5 are associated with inherited arrhythmia syndromes, which are caused by reduced cardiac excitability, particularly Brugada syndrome (BrS) as well as arrhythmogenic right ventricular cardiomyopathy (ARVC). We report a novel pathogenic SCNA5 variant being associated with BrS overlapping with ARVC, as well as disease progression with a previously reported SCN5A variant being associated with a phenotype of BrS and conduction system disorder in two unrelated families.

Defining electrocardiographic criteria to differentiate non-type 1 Brugada ECG variants from normal incomplete RBBB patterns in the young SCD-SOS cohort

INTRODUCTION

We assessed the prevalence of non-type 1 Brugada pattern (T1BrP) in children and young adults from the Sudden Cardiac Death-Screening Of risk factorS cohort and the diagnostic yield of nonexpert manual and automatic algorithm electrocardiogram (ECG) measurements.

METHODS

Cross-sectional study. We reviewed 14 662 ECGs and identified 2226 with a rSr'-pattern in V1-V2. Among these, 115 were classified by experts in hereditary arrhythmic-syndromes as having or not non-T1BrP, and were compared with measurements of 5 ECG-derived parameters based on a triangle formed by r' -wave (d(A), d(B), d(B)/h, β-angle) and ST-ascent, assessed both automatically and manually by nonexperts. We estimated intra- and interobserver concordance for each criterion, calculated diagnostic accuracy and defined the most appropriate cut-off values.

RESULTS

A rSr'-pattern in V1-V2 was associated with higher PQ interval and QRS duration, male gender, and lower body mass index (BMI). The manual measurements of non-T1BrP criteria were moderately reproducible with high intraobserver and moderate interobserver concordance coefficients (ICC: 0.72-0.98, and 0.63-0.76). Criteria with higher discriminatory capacity were: distance d(B) (0.72; 95% confidence interval [CI]: 0.65-0.80) and ST-ascent (0.87; 95% CI: 0.82-0.92), which was superior to the 4 r'-wave criteria together (area under curve [AUC: 0.74]). We suggest new cut-offs with improved combination of sensitivity and specificity: d(B) ≥ 1.4 mm and ST-ascent ≥ 0.7 mm (sensitivity: 1%-82%; specificity: 71%-84%), that can be automatically measured to allow classification in four morphologies with increasing non-T1BrP probability.

CONCLUSION

rSr'-pattern in precordial leads V1-V2 is a frequent finding and the detection of non-T1BrP by using the aforementioned five measurements is reproducible and accurate. In this study, we describe new cut-off values that may help untrained clinicians to identify young individuals who may require further work-up for a potential Brugada Syndrome diagnosis.

The Genetics of Brugada Syndrome

Brugada syndrome is a heritable channelopathy characterized by a peculiar electrocardiogram (ECG) pattern and increased risk of cardiac arrhythmias and sudden death. The arrhythmias originate because of an imbalance between the repolarizing and depolarizing currents that modulate the cardiac action potential. Even if an overt structural cardiomyopathy is not typical of Brugada syndrome, fibrosis and structural changes in the right ventricle contribute to a conduction slowing, which ultimately facilitates ventricular arrhythmias. Currently, Mendelian autosomal dominant transmission is detected in less than 25% of all clinical confirmed cases. Although 23 genes have been associated with the condition, only SCN5A, encoding the cardiac sodium channel, is considered clinically actionable and disease causing. The limited monogenic inheritance has pointed toward new perspectives on the possible complex genetic architecture of the disease, involving polygenic inheritance and a polygenic risk score that can influence penetrance and risk stratification. Expected final online publication date for the Annual Review of Genomics and Human Genetics, Volume 23 is October 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Coved and Saddleback ST-Segment Elevations: Brugada Phenocopy vs Brugada Syndrome

We report a case of a middle-aged man who presented with near syncope, fever, and dysuria and was incidentally found to have coved ST-segment elevations in leads V1 and V2 confirming Brugada type 1 ECG (electrocardiogram) pattern. This ECG pattern morphed into saddleback ST-segment elevations in precordial leads consistent with type 2 Brugada the following day. Additionally, the patient reported a positive family history of sudden cardiac death. This initial presentation made it impossible to differentiate Brugada phenocopy (BrP) from Brugada syndrome (BrS). Continuous cardiac monitoring was initiated, electrophysiology consulted and fever managed with antipyretics. The patient was diagnosed with prostatitis and bacteremia from E. coli and managed with antibiotics. There were no electrolyte abnormalities nor was the patient on any medications other than tamsulosin for his chronic benign prostate hypertrophy. Once the fever resolved the patient's ECG returned to normal, thus confirming the diagnosis of BrS on day 3 post-admission. Differentiating between BrP and BrS requires ruling out possible underlying causes and determining if resolution in ECG patterns occurs.

Brugada Electrocardiogram Pattern Induced by Recreational Delta-8-Tetrahydrocannabinol (THC): A Case Report

Brugada electrocardiogram (ECG) pattern describes a characteristic right bundle branch block (RBBB) appearance with persistent ST-segment elevation in precordial leads V1 to V3, often associated with Brugada syndrome, a genetic sodium channelopathy, in the absence of ischemic or structural heart disease. Known triggers such as fever, electrolyte abnormalities, medications, or recreational drugs may elicit such an ECG pattern without a clear clinical significance yet creating a dilemma for clinicians providing care in the urgent setting. We present a case of reversible Brugada electrocardiogram pattern (BEP) after recreational use of delta-8-tetrahydrocannabinol (THC) and explore the need for further research on the safety of such an over-the-counter supplement.

Case Report: Coexistent Wolff-Parkinson-White Syndrome and Brugada Phenocopy in a Patient With Pneumonia and Myocarditis

Background: In recent years, Wolff-Parkinson-White (WPW) syndrome and Brugada electrocardiogram (ECG) patterns have been reported as coexistent in the same patient. In most cases, the two waveforms appeared separately. Here, we described combinations of different waveforms on one ECG, such as the Brugada pattern with delta waves and the Brugada pattern with paroxysmal supraventricular tachycardia (PSVT). Importantly, we recorded an alternate conversion of these combined ECG waveforms, which has not previously been reported in the literature. At the same time, we confirmed that the change in the waveform was related to fever by analyzing Holter data.

Case: A 48-year-old male was admitted to our hospital due to palpitations and fever. The patient had a history of a cold 3 days ago. Laboratory examinations showed an elevated neutrophil percentage (85%) and troponin I level (0.86 ng/ml). A chest computed tomography (CT) scan showed inflammation in the right lung. The diagnosis of pneumonia and myocarditis was made. ECG indicated WPW syndrome and the Brugada pattern. We recorded the dynamic changes in this combination of delta waves and Brugada waves with a Holter monitor, and we found the changes would happen when the patient's body temperature rose. The doctors thought that the patient's pulmonary infection led to fever, which caused the changes in waveform. After treatment with antibacterial therapy and supportive care, his body temperature returned to normal. The various laboratory indicators also gradually returned to normal. The doctor recommended that the patient undergo further pre-excitation bypass radiofrequency ablation treatment, but the patient refused and was discharged.

Conclusion: Delta waves and Brugada ECG patterns could appear on one ECG at the same time. There were dynamic changes of QRS complex, relating to fever.

Brugada ECG pattern in hypertrophic cardiomyopathy: Brugada phenocopy or overlapping syndrome?

The term phenocopy indicates a condition that imitates one produced by a gene and is also used for acquired Brugada-like ECG manifestations. Cases of Brugada phenocopies are increasingly reported in literature and an international registry is ongoing. We describe two patients with Hypertrophic Cardiomyopathy (HCM) and Brugada ECG pattern. Both patients carried the same pathogenic splicing mutation in MYBPC3 gene (responsible for HCM) while no genetic mutation associated with Brugada Syndrome was identified. To the best of our knowledge, Brugada ECG pattern has been rarely reported in patients with HCM.

Brugada syndrome

Brugada syndrome (BrS) is an inherited cardiac arrhythmia syndrome that causes a heightened risk for ventricular tachyarrhythmias and sudden cardiac death. BrS is characterised by a coved ST-segment elevation in right precordial leads. The prevalence is estimated to range between 1 in 5,000 to 1 in 2,000 in different populations, with the highest being in Southeast Asia and in males. More than 18 genes associated with BrS have been discovered and recent evidence has suggested a complex polygenic mode of inheritance with multiple common and rare genetic variants acting in concert to produce the BrS phenotype. Diagnosis of BrS in patients currently relies on presentation with a type-1 Brugada pattern on ECG either spontaneously or following a drug provocation test using a sodium channel blocker. Risk assessment in patients diagnosed with BrS is controversial, especially with regard to the predictive value of programmed electrical stimulation and novel ECG parameters, such as QRS fragmentation. The first line of BrS therapy remains an implantable cardioverter defibrillator (ICD), although radiofrequency catheter ablation has been shown to be an effective option in patients with contraindications for an ICD. True BrS can be unmasked on ECG in susceptible individuals by monitoring factors such as fever, and this has been recently evident in several patients infected with the 2019 novel coronavirus (COVID-19). Aggressive antipyretic therapy and regular ECG monitoring until fever resolves are current recommendations to help reduce the arrhythmic risk in these COVID-19 patients. In this review, we summarise the current knowledge on the epidemiology, pathophysiology, genetics, clinical diagnosis, risk stratification and treatment of patients with BrS, with special emphasis on COVID-19 comorbidity.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

J Point and ST Elevation Resembling Brugada: A Marker of Mortality in Methanol Toxicity

Objective

J point and coved ST elevation in right precordial leads (not produced by coronary artery disease) are still a matter of challenge, especially when resembling Brugada patients. This clinical entity, among asymptomatic individuals with no family history of sudden cardiac death, would be reported in some severely ill patients before ventricular fibrillation. This study investigated the relationship between the electrocardiograms with demographic and laboratory data and also analyzed their association with mortality rate among patients with methanol poisoning.

Methods

The sample consisted of 356 patients who were hospitalized with a diagnosis of methanol poisoning in Faghihi and Namazi Hospitals in Shiraz, Southern Iran, in March and April 2020. In this period, a major outbreak of methanol poisoning had occurred in this area. Furthermore, the study used the data on any recorded complications or mortality during hospital course.

Results

The ECG (BrP) was observed in a total of 20 (5.6%) patients. Its presence was associated with increased mortality, Glasgow coma scale score <3, and blood sugar levels and was inversely associated with PH, O₂ saturation, and calcium levels (P < 0.05).

Conclusions

This study found that certain ECG patterns and laboratory data can be used as prognostic factors of morbidity and mortality in patients with methanol intoxication. Electrocardiography machines are widely available tools, which can be easily used for risk stratification based on the presence of Brugada approximating electrocardiograms among patients with methanol intoxication.

Brugada Pattern Manifesting During Hyperkalemia, Diabetic Ketoacidosis, and Acute Alcohol Intoxication

BACKGROUND Brugada syndrome is a rare ion channelopathy that can lead to sudden cardiac death and lethal arrhythmias in patients without a structural cardiac defect, the most common of which being the gain-of-function mutation of the SCN5a sodium ion channel involving phase 0 of the cardiac action potential. In 2012, BrS electrocardiogram findings were redefined and classified as either congenital Brugada syndrome (BrS) or Brugada phenocopies (BrP). Several etiologies of BrP have been reported, such as metabolic derangements, electrolyte abnormalities, cardiovascular diseases, and pulmonary embolism. CASE REPORT A 28-year-old man presented to the Emergency Department unresponsive. An initial ECG taken by Emergency Medical Services (EMS) was interpreted as a STEMI. An initial ECG in the ED showed a Brugada type I ECG pattern in leads V1-V2 and hyperacute T wave abnormalities, among other findings. Additionally, the patient had a serum potassium level of 9 mmol/L, glucose level of 1375 mmol/L, and peak cardiac troponin-I of 20.452 μg/L. All underlying medical conditions were stabilized, electrolyte and metabolic abnormalities were corrected, and subsequent normalization of electrocardiographic findings was achieved. CONCLUSIONS Distinguishing congenital Brugada syndrome from Brugada phenocopies can be difficult, especially when patients present to the ED with severe underlying conditions. Several factors can be used to direct clinical suspicion towards one or the other; however, confirmation may require EP studies and further tests. In this case, the following findings were suggestive of BrP: presence of an identifiable underlying abnormality, correction of the underlying condition resolves the ECG pattern, and the absence of family history of sudden cardiac death.

Brugada Pattern Phenocopy Induced by Diabetic Ketoacidosis

Brugada syndrome is a congenital cardiac channelopathy characterized by ST-segment elevation (≥2 mm) and subsequent inverted T wave in a minimum of two right precordial leads (Brugada type 1 ECG [electrocardiogram] pattern) on ECG. Brugada syndrome is estimated to be responsible for 4%-12% of all sudden cardiac deaths and up to 20% in patients with structurally normal hearts. Development of a temporary Brugada pattern, known as Brugada phenocopy, has been observed in individuals presenting with reversible underlying conditions such as hyperkalemia, hyponatremia, acidosis, ischemia, and pulmonary embolism, among others. Herein we present a case of Brugada phenocopy seen in a patient in diabetic ketoacidosis, which resolved after the electrolyte abnormalities were corrected.

Brugada Pattern: Unraveling Possible Cardiac Manifestation of SARS-CoV-2 Infection

We report the case of a 41-year-old patient with no family history of sudden cardiac death. The patient presented with high fever and vomiting and was diagnosed with acute pyelonephritis. Screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was positive. An electrocardiogram (ECG) performed during a fever episode revealed a Brugada pattern. Fever can be a trigger for induction of the electrocardiographic Brugada pattern but it is still unknown if the cardiac involvement by coronavirus disease 2019 (COVID-19) can interfere with myocardial ion channels.

A Continuous Murmur as the Only Clinical Sign for Complex Coronary Artery Fistulas Diagnosis

An asymptomatic patient presented at our hospital exhibiting a Brugada electrocardiography pattern with coronary artery fistulas. Coronary artery fistula is a congenital or acquired rare abnormal condition with increased symptoms and complications over time. In the absence of the therapeutic consensus, we discuss the association and management for this condition. (Level of Difficulty: Advanced.).

Type 2 Brugada Electrocardiogram Pattern Due to Supra-Therapeutic Phenytoin Level

Brugada syndrome (BS) is a hereditary cardiac disease leading to sudden cardiac death. It does not display any structural cardiac abnormalities. It was first described in 1992, as the syndrome of ‘right bundle branch block, persistent ST segment elevation, and sudden death.’ Brugada phenocopy (BP) is a relatively new term used to describe electrocardiogram (ECG) patterns that resemble BS but are due to other reversible causes such as electrolyte abnormalities, fever, cocaine or alcohol intoxication, and side effect of certain medications such as sodium channel blockers, beta blockers, antidepressants, alpha adrenergic blockers, etc. Earlier studies have shown that patients taking sodium channel blocking antiepileptic drugs (AEDs) especially phenytoin can have Brugada type 1 like ECG pattern. Previously, type 2 ECG pattern secondary to supra-therapeutic phenytoin level has not been described. We describe a case with type 2 Brugada ECG pattern due to supra-therapeutic phenytoin level; the ECG pattern completely resolved following lowering the phenytoin to a therapeutic level. These patients need special considerations in ED management, disposition, and follow-up.

Brugada syndrome clinical update

Brugada syndrome (BrS) was initially described in southeast Asians with a structurally normal heart presenting with polymorphic ventricular tachycardia and fibrillation. This condition is marked by J-point elevation ≥ 2 mm with coved-type ST segment elevation followed by negative T wave inversions in at least one precordial lead (V1 or V2) when other etiologies have been excluded. These changes on electrocardiogram (EKG) can either be spontaneous or manifest after sodium channel blockade. The worldwide prevalence of BrS is about 0.4%; however, it is higher in the Asian population at 0.9%. This article will review the current hypotheses regarding the pathophysiology, spectrum of clinical presentation, strategies for prevention of sudden cardiac death and the treatment for recurrent arrhythmias in BrS.

Role of Provocable Brugada ECG Pattern in The Correct Risk Stratification for Major Arrhythmic Events

The so-called Brugada syndrome (BS), first called precordial early repolarization syndrome (PERS), is characterized by the association of a fascinating electrocardiographic pattern, namely an aspect resembling right bundle branch block with a coved and sometime upsloping ST segment elevation in the precordial leads, and major ventricular arrhythmic events that could rarely lead to sudden death. Its electrogenesis has been related to a conduction delay mostly, but not only, located on the right ventricular outflow tract (RVOT), probably due to a progressive fibrosis of the conduction system. Many tests have been proposed to identify people at risk of sudden death and, among all, ajmaline challenge, thanks to its ability to enhance latent conduction defects, became so popular, even if its role is still controversial as it is neither specific nor sensitive enough to guide further invasive investigations and managements. Interestingly, a type 1 pattern has also been induced in many other cardiac diseases or systemic diseases with a cardiac involvement, such as long QT syndrome (LQTS), arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM) and myotonic dystrophy, without any clear arrhythmic risk profile. Evidence-based studies clearly showed that a positive ajmaline test does not provide any additional information on the risk stratification for major ventricular arrhythmic events on asymptomatic individuals with a non-diagnostic Brugada ECG pattern.

An unusual ECG change after a car crash

A 34‐year‐old male patient was preparing for splenic artery embolization because of a car crash. Personal or family histories of cardiovascular diseases, sudden cardiac death, or Brugada syndrome were denied. Type 1 Brugada pattern was observed in the preoperative electrocardiogram and gradually resolved within a week. Chest blunt trauma may contribute to the transient ECG changes, and some particular considerations should be taken in this patient.

Importance of thorough investigation in a patient presenting with recurrent collapse and ST elevation

There is increasing literature to suggest numerous subgroups of Brugada syndrome (BrS), including those with ST elevation in the lateral or inferior leads. We present a case of a patient presenting with recurrent collapse and inferior ST elevation degenerating to ventricular fibrillation and ultimately leading to a diagnosis of BrS.

Hyperkalemia induced Brugada phenocopy

We illustrate the case Brugada Type 1 pattern on electrocardiogram in a setting of hyperkalemia, changes which were reversible following normalization of serum potassium levels. Although Brugada Type 1 syndrome is associated with sudden cardiac death, a quick search for alternate reversible pathology is essential to timely management and avoid unnecessary cardiac intervention.